INDIANA DEPARTMENT OF REVENUE FT-501X Amended Terminal Operator's Monthly Return SF# 47736 (R3 \ 12-08) Due date is the 20th of the following month. For the month of:_________________, 20_____ A Terminal Operator's Report Must Be Filed for Each Indiana Location Being Amended License Number Name of License Holder (as indicated on license) Mailing Address Federal 637 License Number State City or Town Zip Code FEIN/SSN Business Telephone Number Terminal Information Terminal Code Name of Terminal Location Net Gallons as Previously Reported From Schedule Monthly Transactions For Owned/Leased Terminal Space Column A Special Fuel (Dyed and Clear Diesel Fuel, Biodiesel, Blended Biodiesel) Column B Gasoline (Gasoline, Gasohol) Net Gallons As Amended Column A Column C Other Prod- Special Fuel ucts (Dyed and (Jet Fuel, Clear Diesel Kerosene) Fuel, Biodiesel and Blended Biodiesel) Column B Gasoline (Gasoline, Gasohol) Column C Other Products (Jet Fuel, Kerosene) 1. Beginning Physical Inventory 2. Total Receipts 501A 3. Total Disbursements 501B 4. Stock Gains & Losses + - 5. Ending Physical Inventory (Line 1 plus Line 2 minus Line 3 plus/minus Line 4) Mail Return To: Indiana Department of Revenue P.O. Box 6080 Indianapolis, IN 46206-6080 I do hereby certify under penalty of perjury that, for the terminal location indicated above, the foregoing and attached schedules and reports are a true and correct statement to the best of my knowledge and is a complete and full presentation of all transactions from the best information available. Taxpayer or Authorized Agent Typed or Printed Name Title Date Signed Telephone Number Please Check Box If Last Filing ❑ American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Amended Terminal Operator's Monthly Return (FT-501X) Who Should File This Return? You should file this form if you are an Indiana Licensed Special Fuel Terminal Operator and you need to amend or change a previously filed Terminal Operator’s Monthly Tax Return, Form FT-501. How Do I Complete the FT-501X? You should refer to the instructions for your original Terminal Operator’s Monthly Tax Return, and related schedules, for the tax period being amended. Enter your company’s identifying information on form FT-501X and all accompanying schedules. Complete all information, leaving nothing blank. It is critical that you use the same license number on this report that is shown on your actual license. A separate FT-501X must be filed for each tax period requiring an amendment. Billed Gallons as Previously Reported: Complete lines 1 through 5 of Column A, Column B and Column C by entering the amounts as reported on your original tax return, or as previously amended. (If previously amended, lines 1 through 5 will be the amounts reported in column titled “Billed Gallons as Amended” of the previously filed amended return.) Billed Gallons as Amended: Use this column to report changes in line amounts from those previously reported. Changes in column titled “Billed Gallons as Amended" must be documented by attaching the corresponding schedules, as amended. If there is no change to a particular line entry, enter zero. To Obtain Forms Visit our web site on the Internet and download the forms you need. Our address is: www.in.gov/dor/. What if I Have Other Questions? If you have other questions, contact our office by calling 317-615-2630, or by writing to: Indiana Department of Revenue P. O. Box 6080 Indianapolis, IN 46206-6080 American LegalNet, Inc. www.FormsWorkflow.com